Robotic-assisted minimally invasive esophagectomy (RAMIE)—leveraging the advantages of robotics compared to conventional thoracoscopic surgery

Esophagectomy with lymph node dissection (LND) is widely accepted as the standard surgical procedure for treating thoracic esophageal cancer. In particular, because of the high frequency of lymph node (LN) metastases along the recurrent laryngeal nerve (RLN), meticulous and adequate LND is considered crucial for better local control as well as accurate staging. However, this procedure is technically demanding, and it also frequently results in RLN palsy, which may lead to severe postoperative pulmonary complications.

Minimally invasive esophagectomy (MIE) has shown potential for reducing postoperative complications compared with open esophagectomy (OE) while allowing a quicker return to normal function (1,2). However, conventional MIE (cMIE) requires substantial technical skill, as it must be performed with a straight instrument and within the narrow mediastinal space and limited intercostal space located near vital organs, such as the trachea and aorta. Recently, robotic surgery has revolutionized the field of esophageal surgery, providing enhanced precision, skill, and visualization (3,4).

Key benefits of robot-assisted minimally invasive esophagectomy (RAMIE) include improved visualization using a magnified three-dimensional (3D) camera and allowing for full articulation of the instruments. In addition, the robotic system also allows for tremor filtering and motion scaling, thus enabling surgeons to perform precise manipulations, even in narrow surgical fields. Meanwhile, the same is true for other gastrointestinal procedures, RAMIE also has several drawbacks. First, the lack of tactile sensation is always associated with an increased risk of damaging the tissue and organs. However, with recent research on force feedback technology, this is likely to be overcome to some extent in the near future (5). Second, compared to cMIE, the longer operation time and higher medical costs remain a major problem to be solved. Regarding to operating time, the difference time between RAMIE and cMIE has gradually been reduced at institutions with more experience in RAMIE, due to the standardization of procedures (6,7).

In this editorial commentary, we would like to focus on three potential benefits of RAMIE, for which solid evidence will be established in the near future. First, robotic approach is expected to perform more sophisticated LND along the left RLN, which is the most complex procedure requiring both a higher number of retrieved LNs and a lower incidence of RLN palsy. The robot allows surgeons to perform ergonomically free two-handed dissection, contributing to reduce the surgeon’s physical and psychological stress in this area (Video 1). While many previous institutional reports and systematic reviews have predominantly reported that RAMIE has a similar frequency of RLN palsy compared to cMIE (3,4,8,9), the REVATE trial (7), which was a pivotal randomized controlled trial (RCT) comparing RAMIE and cMIE, recently revealed the RAMIE was associated with a higher success rate in LN dissection along the left RLN (88.3% of the RAMIE group and 69% of the cMIE group; P<0.001) (the success was defined as the removal of at least one LN without causing RLN palsy lasting longer than 6 months). In another pivotal RCT [the RAMIE trial (6)], RAMIE have demonstrated a higher achievement rate of LND along the left RLN in patients who received neoadjuvant therapy compared with cMIE (79.5% vs. 67.6%, P=0.001) with similar incidences of RLN palsy (Table 1). It is anticipated that future studies will demonstrate the effectiveness and comfort of robotic approach during LND along the left RLN, as experienced by surgeons in practice.

The second potential benefit of robotic procedure is the intrathoracic side-to-side linear-stapled anastomosis in Ivor Lewis esophagectomy (ILE). In Asia as well as Japan, nearly 90% of esophageal cancers are squamous cell carcinoma, and most of them are treated with McKeown approach as the standard surgery (10). Meanwhile, the patients with adenocarcinoma in the esophago-gastric junction are gradually increasing and ILE is considered the optimal procedure for them. However, unlike circular-stapled anastomosis, linear-stapled intrathoracic anastomosis in cMIE is an unfamiliar and challenging procedure compared with cervical anastomosis for Asian surgeons (11). Recently, we reported the benefit of RAMIE compared to cMIE in a side-to-side linear-stapled anastomosis (12). Compared with the cMIE group, no anastomotic leakage was observed in the RAMIE group (17.5% vs. 0, P=0.035). Rates of total complications (50.9% vs. 25%, P=0.052) and median length of hospital stay (19 vs. 15 days, P=0.080) also tended to be reduced in the RAMIE group, but did not reach significance. Robotic techniques can dramatically reduce the difficulty of intrathoracic anastomosis and further contribute to a reduction in postoperative anastomosis-related complications (Video 2).

The third potential benefit of RAMIE is enhanced learning effects for trainee surgeons. Several investigators have demonstrated a short learning curve for RAMIE (13-15). Park et al. demonstrated that at least 20 operations are needed for experienced surgeons to gain early proficiency in RAMIE (13). Yang et al. reported that after the initial learning phase of 40 cases, the participants reached a plateau regarding the estimated blood loss, the rate of conversion to OE, and the number of harvested LNs (15). However, these insights have largely been derived based on the work of experienced-surgeons in cMIE, which makes it impossible to draw any firm conclusions regarding the learning curve for RAMIE. However, the dual console in robotic system is considered a powerful educational tool, which enables both the attending and trainee surgeons to perform RAMIE together, and attending surgeon can give leading assistance in 3D screen in real time. The actual learning effect in RAMIE should be verified in future prospective studies.

In conclusion, robotic surgery is introducing several significant advancements in esophageal cancer surgery and is expected to improve patient outcomes. With the further advancement of technology and the increasing experience of surgeons in RAMIE, robotic surgery will continue to play an essential role in the treatment of esophageal cancers.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Esophagus. The article has undergone external peer review.

Peer Review File: Available at https://aoe.amegroups.com/article/view/10.21037/aoe-24-22/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://aoe.amegroups.org/article/view/10.21037/aoe-24-22/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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